Claims Adjudicator

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

Responsible for the accurate and timely processing of claims while meeting established quality and productivity standards. Also, responsible for simple adjustments to previously processed claims.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key Functions/Responsibilities

• Provide general claims support by reviewing, researching, investigating, processing and adjusting claims.
• Identify trends and report to Supervisor as necessary.
• Review and analyze data from system-generated reports for in-process claims in order to identify and resolve errors prior to final adjudication.
• Consistently meet established productivity, schedule adherence and quality standards
• Provide general claims support by reviewing, researching, investigating, processing and adjusting claims.
• Other duties as assigned
• You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Qualifications:

Education Required:

·       High School Diploma / GED (or higher)

Education Preferred:

·       Associate degree or some college coursework (preferred)

Experience Preferred/Desirable:

• 2+ years of administrative experience (i.e. office, administrative, clerical, customer service, etc.)
• 1+ years of experience processing medical, dental or prescription claims
• Experience with Facets system

Competencies, Skills and Attributes

• Familiarity with UB04’s and CMS 1500’s
• Experience with Microsoft Excel (ability to create, edit, filter and sort through spreadsheets)
• Experience with Microsoft Word (ability to create and edit documents)
• Experience with Microsoft Outlook (ability to send/receive emails and calendar invites)
• Understand and maintain HIPAA confidentiality and privacy standards when completing assigned work
• Proficiency with computer and Windows PC applications, which includes the ability to learn new and complex computer system applications
• Navigate across various computer systems to locate critical information.
• Attention to detail to ensure accuracy, which will support timely processing of the member's claim.
• Strong communication skills (internally and externally).
• Ability to work with minimal supervision while meeting deadlines.

Working Conditions and Physical Effort: 

• Regular and reliable attendance is an essential function of the position
• Ability to work OT during peak periods. 

Telecommuting Requirements

• Required to have a dedicated work area established that is separated from other living areas and provides information privacy
• Ability to keep all company sensitive documents secure (if applicable)
• Must live in a location that can receive an approved high-speed internet connection or leverage an existing high-speed internet service

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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